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SERVICE REQUEST <br /> rType of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 PERAT BI ING PA <br /> FACiury NAME <br /> - <br /> SITE c/cSc�SS <br /> Street Number Direction Street Name Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> CITY �__. STATE ZIP <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> IrWo <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS tJAME C �_. PHONE# Q EXT. <br /> G ADD S FAX# <br /> C STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH D ISION hourly charges associated with this project or activity will be billed tome or my business as identified on this form. <br /> I also certify that I have pepared lication that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes.Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: C.E/O DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER �Q!'--' —UTHER AUTHORIZED AGENT <br /> If APPucAmT is not the BIUJNG PAR proof of authorization to sign is required T i t I e <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> DEC 15 1999 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIG TORE: CONTRACTOR'S SIGNATURE: <br /> �PPnvVEvoY. —_• (1 EMPLQYEE#: �J� I DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already com letedt: SERVICE CODE: Peri E 2 <br /> Fee Amount: Amount Paid 3 Payment D to <br /> Payment Type Invoice# Check# j Received By: <br />